Care Hub components for the highest quality geriatric care.
Transitional care
Care Hub care paths place an emphasis on transitional care at admission and at the time of discharge. We focus on communication between acute and post-acute care providers, attention to medication optimization, as well as timely follow-up on laboratory investigations and specialist appointments.
Advance care planning
Advance Care Planning (ACP) provides residents, patients and families the opportunity to discuss their perspectives about goals of care. Care Hub care paths include a periodic focus on ACP by practitioners at the time of transitions and as needed to assure patient wishes are honored.
Medication reviews
Care Hub care paths prioritize periodic medication reviews, appropriate deprescribing and education of patients and families about their medications. Our dashboards track the deprescribing of medications to improve health outcomes, save nursing time, and minimize iatrogenic harm.
Chronic disease management
Care Hub care paths promote proactive follow up visits and an incremental approach to review the status of various chronic comorbidities among patients and residents. It is crucial that the patient and family are comfortably focused on their chronic illnesses to provide input into care planning for these issues. Care Hub risk-assessments set the frequency of these visits.
Staff and patient/family education
High quality outcomes need staff that are knowledgeable and have the proper skills to care for specific issues among frail patients. Care Hub care paths include a focus on regular interdisciplinary grand-rounding processes to improve staff and also engage patients and their families in their own care.